| Dental Cleaning - Adult | $109 | 0% | $109 | 
Medium |
| Dental Cleaning - Child | $88 | 0% | $88 |
Medium |
| Dental Exam - Comprehensive | $149 | 0% | $149 |
Medium |
| Dental Exam - Periodic, Established Patient | $51 | 0% | $51 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $165 | 0% | $165 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $321 | 0% | $321 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | 0% | $231 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $156 | 0% | $156 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $161 | 0% | $161 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $306 | 0% | $306 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $238 | 0% | $238 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $226 | 0% | $226 |
Medium |
| Fluoride - Topical Application | $45 | 0% | $45 |
Medium |
| Maintenance Therapy - Periodontal | $158 | 0% | $158 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $118 | 0% | $118 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $275 | 0% | $275 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | 0% | $92 |
Medium |
| Root Canal - Anterior Tooth | $2,098 | 0% | $2,098 |
Medium |
| Root Canal - Bicuspid Tooth | $1,162 | 0% | $1,162 |
Medium |
| Root Canal - Molar | $1,399 | 0% | $1,399 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | 0% | $60 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $190 | 0% | $190 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
Medium |
| X-Ray - Complete Intraoral Series | $167 | 0% | $167 |
Medium |
| X-Ray - Four Images, Bitewings | $78 | 0% | $78 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | 0% | $33 |
Medium |
| X-Ray - Two Images, Bitewings | $62 | 0% | $62 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $179 | 0% | $179 |
Medium |
